Multiple System Atrophy

Multiple System Atrophy (MSA) is a progressive brain disease featuring

poor coordination and balance,

slowness and stiffness, and

sympathetic nervous system abnormalities among other problems.

MSA is also characterized by postural (or orthostatic) hypotension and excessive drop in blood pressure when the patient stands up, which causes dizziness or momentary blackouts. MSA has been classified clinically into three types: olivopontocerebellar atrophy (OPCA), which primarily affects balance, coordination and speech; a Parkinsonian form (striatonigral degeneration), which can resemble Parkinson’s disease because of slow movement and stiff muscles; and a mixed cerebellar and Parkinsonian form.

What is MSA?

MSA is rare, with about 13,000 sufferers in the United States, most of whom have not yet received a correct diagnosis. This compares with about 20,000 with progressive supranuclear palsy (PSP), which is a similar condition, about 500,000 with Parkinson’s disease and five million with Alzheimer’s disease.

New cases of MSA arise in about six persons per million per year. This means that in the U.S., about five people are newly diagnosed with MSA each day

There are three types that grade into one another. MSA emphasizing slowness and stiffness was once called striatonigral degeneration. MSA emphasizing autonomic problems was called Shy-Drager syndrome and cases emphasizing cerebellar problems were called sporadic olivopontocerebellar atrophy. These terms were discarded in 1989, when all three were found to be variants of the one disease, which then received its current name. What they all have in common is a type of protein that forms clumps in the same types of cells in the three. The differences among the three types of MSA are dictated by which parts of the brain or spinal cord are most involved.

What Causes MSA?

The ultimate cause (called the etiology of the disease) is not known. MSA almost never occurs twice in a family and there are no confirmed clusters related to occupation, industry, diet, ethnicity or geography. A variant in a gene called alpha-synuclein (SNCA) occurs more often in people with MSA than in the rest of the population, but this accounts for only a small fraction of the overall cause of the disease. Various chemical toxins have also been implicated, but these results have not been confirmed in multiple studies.

The direct cause of the loss of brain and spinal cord cells (the pathogenesis of the disease) in people with MSA is not fully understood. However, it has to do with the clumps of alpha-synuclein protein mentioned above. Alpha-synuclein is a normal protein that is necessary for brain cells to signal to one another. The current favored theory is that too much alpha-synuclein is made. Once it reaches a certain concentration in the cell, it starts to stick together. The resulting blobs, when they are still too small to be seen with a microscope, are toxic. The larger clumps seen under the microscope, called glial cytoplasmic inclusions, may actually be the brain’s attempt to solidify the tiny, toxic clumps floating around inside the cell into a hard, relatively harmless form.

The same protein, alpha-synuclein, accumulates in the brain cells in Parkinson’s disease, but in somewhat different parts of the brain. Also, in MSA, the initial accumulation and cells loss appears to be in the glia, the electrically inactive supporting cells of the brain. In Parkinson’s disease, on the other hand, the problem starts in the neurons, the electrically active cells.

All three kinds of MSA feature important balance problems that can eventually require assistance in walking or even a wheelchair. All three types can also display difficulty in the aspect of thinking called executive function. This is what allows us to organize information by categories, understand abstractions and instructions, create and follow a plan and inhibit inappropriate actions. These things often decline to some extent in people with MSA.

Some other features occur in all three types of MSA. Perhaps the most important is difficulty swallowing, which obliges one to modify the diet to exclude thin liquids or tough solids. All three types can also have difficulty in moving the eyes, which can interfere with reading; and in speaking, which may require speech therapy and communication devices.

People with MSA of the parkinsonian type tend to get more muscle stiffness and general slowness. Those with the cerebellar type develop a coarse tremor when moving the limbs and difficulty aiming their limb movements or walking in a straight line, much like someone who is drunk. Those with MSA that emphasizes the autonomic problem have a variety of symptoms including urinary urgency and incontinence, constipation, erectile disturbance in men, lightheadedness or even fainting upon standing, noisy or irregular breathing, sleep disruption and difficulties with temperature regulation. Most people with MSA have some combination of the three types rather than a pure form.

Some other problems with movement can occur in MSA. The hands can gradually assume abnormal, fixed postures called dystonia. This can be prevented to some degree by stretching exercises and can be treated in some cases by botulinum toxin (Botox) injections into the hands or forearms. Some people with MSA hold their heads bent forward to an extreme degree, a condition called antecollis. This may respond to Botox injected into the neck muscles, although care must be taken not to exacerbate the swallowing problems via leakage of the Botox to the immediately adjacent muscles. Another issue in some people is sudden, rapid jerks of a limb or of the trunk that is annoying but almost never large enough to interfere with normal movement. This called myoclonus and can be treated with medication. Finally, a tremor, which is not nearly as prominent as in most people with Parkinson’s, can occur in MSA. This tremor generally occurs when the limb is in use rather than at rest as in PD. It may respond to medication, but usually is too mild to require treatment.

Some people with MSA develop obstructive sleep apnea. This is where the upper airway tends to close during sleep, which causes insomnia and sometimes insufficient blood oxygen levels. It can be treated by wearing a mask during sleep that connects to a kind of air pump that keeps the airway open, called continuous positive airway pressure or CPAP. This is usually best managed by a specialist in sleep medicine or pulmonary medicine rather than a neurologist.

On average, someone with MSA lives about seven or eight years after the onset of symptoms. This short survival is not a direct effect of the disease, but of complications of the difficulties in swallowing safely and moving around. The most common of these complications are pneumonia, urinary tract infections and blood clots in the legs that lodge in the lungs. Other potentially dangerous complications of MSA are low blood pressure, slow heart rate, sleep apnea and injuries from falls.

Disease Management

We have no treatment or prevention for the underlying brain disorder, but some of the individual symptoms can be managed successfully with medication that raise blood pressure, enhance sleep, inhibit bladder emptying or stimulate the bowel. Drugs for PD that stimulate the brain’s dopamine system sometimes work for a few years for the general slowness and stiffness in MSA.

Unfortunately, the progression of MSA is almost as rapid as that of PSP, with the average time from initial symptom to requiring a wheelchair of five years. Death occurs an average of seven to eight years after the initial symptom, usually from complications of the immobile state such as pneumonia or other infections. Keep in mind that this is only an average duration of survival. Many people with MSA survive longer.

A critical defect in the brain cells in MSA is accumulation of the normal protein “alpha-synuclein.” The same protein accumulates in Parkinson’s disease, but in a different set of brain cells. In 2010 alone, 227 research papers on MSA were published in scientific journals. As scientists understand more about the various brain degenerative disorders such as Alzheimer’s, Parkinson’s, PSP, Lou Gehrig disease and MSA, many commonalities among them are being revealed. That means that any breakthrough in one could benefit the others. It is entirely realistic to expect that after researchers find a prevention or a way of halting the progression of one of these diseases, the others will benefit similarly

One way is to be alert for trials of new medication or new diagnostic tests. These are listed on a website maintained by the National Institutes of Health, www.clinicaltrials.gov. You simply enter “Multiple System Atrophy” into the search box. Participants in clinical trials may not only benefit from a new treatment that is not generally available, they also often receive detailed care and attention that is not part of the routine, even at excellent medical centers. They also get the satisfaction of helping in the fight against their illness. Other trials may look for new genetic or environmental contributors to the cause of MSA. Discovering these could also point to potential preventative measures or treatments.

CurePSP Network of Support

CurePSP offers a network of support, to patients and their families, other caregivers, physicians and allied health professionals. If you do not find the information you need here, please call our office at +1 347-294-2873 or write us an e-mail to info@curepsp.org, and we will help you.

Should I Join a Support Group?

There can be great value in joining a group of other people with the same problem:

You can exchange helpful tips on ways to cope physically and psychologically with the limitations of the illness.

You can learn more about the disease, and its treatment, from people who are experiencing or had close exposure to MSA.

CurePSP has created a network of approximately 50 successful MSA/CBD/PSP support groups in the U.S. If you feel like finding a support group near you, visit this page. Many large medical centers have a Parkinson support group that welcomes members with MSA.

If you feel like establishing your own support group, have a look at our resources here, and contact Joanna Teters at info@curepsp.org or call her at 347-294-2871. Remember, all it takes is one organizer with some time and energy to make all the difference in the world.

CurePSP favors projects with the potential to produce preliminary findings that would support an application to a government agency for a much larger grant in the future. It does not restrict its grants to any country or continent. Please visit our research pages to learn more how we support science.

Another way to help research and yourself is to participate in clinical trials. Please visit our clinical trials page for more information. Also, please register with the FTD Disorder Registry to become involved with clinical trials.

What is a Brain Donation?

Another very important way to help MSA research is to make arrangements to donate your brain after death. CurePSP supports the the brain bank located at the Mayo Clinic in Jacksonville, FL. Brains donated there are stored and used only for research in MSA by legitimate researchers who request it. Donating to a brain bank does not interfere with funeral arrangements and costs a few hundred dollars for expenses of brain removal and transportation, which may be reimbursed by CurePSP. The family will receive, at no charge, a full diagnostic report from the Mayo Clinic pathologist, Dennis W. Dickson, MD, who is one of the world’s foremost authorities on MSA and related disorders. Further information is available from CurePSP or by calling the Brain Bank directly at 904-953-2439. There are several other brain banks throughout the country, generally located at major university hospitals.

Prime of Life: A Family’s Story

This channel features 41 that explain various ways to get through a day of normal activities such as sitting down in a chair, putting on a shirt and using a walking frame, among many others. Many patients and support group members have found these videos to be extremely useful tools to help manage symptoms.

Getting Out Of Bed

This video demonstrates how patients can get out of bed with and without the assistance of a handrail. This how-to series, made possible by the Norma Oppenlander Fund, is designed to provide persons afflicted with PSP, CBD and related diseases with demonstrations of techniques that can be utilized to make daily tasks easier to perform.

Brochures and Resources

A key part of CurePSP’s mission of care, consciousness, and cure is to provide all relevant, up-to-date information on prime of life brain diseases. These resources are for patients, families, and friends seeking to educate themselves, and others, about these diseases; the causes, the symptoms, the disease trajectory, treatments, management, etc. This information is sourced from credible peer-reviewed scientific sources only, and is updated as breakthroughs in our understanding of these diseases occur.

We are proud to bring you the 2018 CurePSP Guidebook. This signature publication features 150 pages of the latest information on PSP, CBD, and MSA and is the perfect reference for patients, family, carepartners, and health professionals. The Guidebook is available for a suggested donation of $20, email saunders@curepsp.org to get your copy. Click the image to read the Guidebook online.

Click the image to read the PSP Some Answers online.

Request For Information

As part of our mission of Care, Consciousness, and Cure, CurePSP has collated the most relevant, up-to-date information available on PSP, CBD and MSA, and is happy to post to you all materials in our “Request For Information” package. The information package includes various informational brochures, instructional DVDs, and medical alert cards. As the production of these materials has been paid for by donors, we kindly ask you to help the next person who needs them by making a contribution here. To submit your request, click the link below and provide the information requested in the form.